Bedford County Volunteer Application

Volunteer Application
Bedford County Department of Fire & Rescue

Which division would you like to apply for?

FIRE or RESCUE ?

Primary area of interest?

APPLICANT INFORMATION

First Name	MI	Last Name	Suff
Street
City	State	Zip
Home Phone	Work Phone

SSN#

VA Driver's Lic#

mm/dd/yyyy
Date of Birth

Occupation

Place of Employment

Previous Experience or Memberships (Fire or Rescue or Military)

Certification and Levels of Training

Please list any physical, mental or emotional disabilities

Previous Fire or EMS affiliation or experiences

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EDUCATION

Name of High School

Highest grade completed

Name of College

Years Completed

REFERENCES

List two persons who are not related to you who know your qualifications or your character

Name	Address	Phone

BACKGROUND CHECK

Drug Screen/Physical

Are you willing to have a yearly drug screening and physical? Yes No

Convictions

Other than violations committed as a juvenile (under 18 years of age),
have you ever been convicted of any violation(s) of the law, felony or misdemeanor?
Yes No

If yes, please explain

Traffic Violation

Have you ever been
Convicted of any traffic violation?
Yes No

If Yes, Please explain

CPS Complaint

Have you ever been a subject of a complaint
through the Child Protective Services?
Yes No

If yes, please explain

CPS Founded Complaint

Have you ever been party of a founded complaint filed with Child Protective Services?
Yes No

If yes, please explain

Why?

Please use this space to explain why you would like to be a Fire or Rescue Volunteer

CERTIFICATION

By clicking on the Certify Checkbox below, I certify that all information provided on this application is true, accurate and complete. In addition, I understand that this certifcation authorizes the Department of Fire & Rescue to investigate my criminal and motor vehicle operation background to verify the information in correct.

The information supplied by me in this application is complete and is true to the best of my knowledge and belief. I understand that misstatement of material facts will cause forfeiture of all my rights to any employment or result in dismissal from employment.

In addition, I grant permission to the Virginia Division of Motor Vehicles to provide copies of my driving record to the Bedford County Department of Fire and Rescue for evaluation purposes only.

All information provided to the Department of Fire and Rescue will remain confidential and will not be released to outside entities except as required by law.

I agree to the conditions of the above certification

Use the scroll arrows to REVIEW YOUR APPLICATION. Make any change desired by typing over the old information. You will be required to sign a paper copy if you are interviewed. This will become an official, permanent record.
	You may print this page before submitting if you wish, by clicking the Print button. Please remember to click the Submit button below after printing!

	Be sure to check the certification box above. You will not be able to submit your application without certification.